decisionhealth Newsletters, Coder Pink Sheets - 2026 Issue 2 (February)
Compliance: Contractor medical director: Cloned time may ‘raise red flags during audits’
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Article Overview
This compliance-focused article reviews guidance discussed at the CPT & RBRVS 2026 Annual Symposium about documenting time for time-based medical services. It is intended for coders, compliance staff, and practitioners who document services by time, and it highlights why specificity in documentation matters for audits, risk management, and accurate coding. The article also includes practical documentation advice from a coding expert and references Medicare contractor perspectives.
Why This Topic Matters
Time-based documentation is a frequent audit focus, and repetitive or templated entries can increase compliance risk. Understanding the article helps practices strengthen documentation habits without exposing themselves to denials or overpayment issues.
Article Sections
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Contractor medical director Q&A on time-based documentation
A symposium Q&A addresses documentation expectations for services billed by time and the broader compliance concerns raised by repeated entries.
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Expert tip: Tie time to work
A coding expert offers general documentation advice about making time entries specific and connected to the work performed.
What You Will Learn
- Why time-based documentation is a compliance concern
- How audit risk can be associated with repetitive time entries
- What general qualities make documentation more specific
- How documentation practices can affect coding accuracy and risk management
Who Should Read This
- Medical coders
- Compliance professionals
- Physicians and other practitioners
- Practice managers
- Revenue cycle staff
Codes Discussed
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